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Animal-Associated Exposure to Rabies Virus among Travelers, 1997–2012 - Volume 21, Number 4—April 2015 - Emerging Infectious Disease journal - CDC

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Animal-Associated Exposure to Rabies Virus among Travelers, 1997–2012 - Volume 21, Number 4—April 2015 - Emerging Infectious Disease journal - CDC





Volume 21, Number 4—April 2015

CME ACTIVITY - Synopsis

Animal-Associated Exposure to Rabies Virus among Travelers, 1997–2012

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Philippe GautretComments to Author , Kira Harvey, Prativa Pandey, Poh Lian Lim, Karin Leder, Watcharapong Piyaphanee, Marc Shaw, Susan C. McDonald, Eli Schwartz, Douglas H. Esposito, Philippe Parola, and for the GeoSentinel Surveillance Network
Author affiliations: Aix Marseille Université, Marseille, France (P. Gautret, P. Parola); Institut Hospitalo-Universitaire Méditerranée Infection, Marseille (P. Gautret, P. Parola); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (K. Harvey, D.H. Esposito); CIWEC Clinic Travel Medicine Center, Kathmandu, Nepal (P. Pandey); Tan Tock Seng Hospital, Singapore (P.L. Lim); Lee Kong Chian School of Medicine, Singapore (P.L. Lim); Monash University, Melbourne, Victoria, Australia (K. Leder); The Royal Melbourne Hospital, Parkville, Victoria, Australia (K. Leder); Mahidol University, Bangkok, Thailand (W. Piyaphanee); Travellers Health and Vaccination Centre, Auckland, New Zealand (M. Shaw); University Hospital of Northern British Columbia, Prince George, British Columbia, Canada (S.C. McDonald); Tel Hashomer and Sackler School of Medicine, Tel Aviv, Israel (E. Schwartz)

Abstract

Among travelers, rabies cases are rare, but animal bites are relatively common. To determine which travelers are at highest risk for rabies, we studied 2,697 travelers receiving care for animal-related exposures and requiring rabies postexposure prophylaxis at GeoSentinel clinics during 1997–2012. No specific demographic characteristics differentiated these travelers from other travelers seeking medical care, making it challenging to identify travelers who might benefit from reinforced pretravel rabies prevention counseling. Median travel duration was short for these travelers: 15 days for those seeking care after completion of travel and 20 days for those seeking care during travel. This finding contradicts the view that preexposure rabies vaccine recommendations should be partly based on longer travel durations. Over half of exposures occurred in Thailand, Indonesia, Nepal, China, and India. International travelers to rabies-endemic regions, particularly Asia, should be informed about potential rabies exposure and benefits of pretravel vaccination, regardless of demographics or length of stay.
Rabies causes ≈60,000 human deaths annually and is a public health concern in most countries in Asia and Africa (1). By contrast, it is rare among travelers; an average of 3.7 cases were documented each year during 2004–2012 (2). Nevertheless, bites to travelers by potentially rabid animals are relatively frequent; estimated incidence is 0.4% per month of stay, according to a meta-analysis of ≈1,270,000 travelers (3). By inference, expensive postexposure prophylaxis (PEP), which includes administration of rabies vaccine and rabies immunoglobulin, is probably provided to large numbers of travelers annually. Given the severity of rabies virus infection and the high costs associated with caring for large numbers of potentially exposed travelers, rabies pretravel preventive measures need to be reinforced. These measures include systematic pretravel counseling about animal bite avoidance, postexposure wound care and prophylaxis, and preexposure rabies vaccination for some travelers.
Generalizability of data regarding the epidemiology of travel-associated animal-related rabies virus exposures are limited because they come from studies that are small or single center or that focus on travelers returning from specific destinations. As such, travelers at highest risk for rabies cannot be reliably identified on the basis of available data (3,4). The decision as to which travelers should receive predeparture rabies vaccination is complex because of the combination of limited data defining rabies risk among travelers, the high cost of rabies vaccine and rabies immunoglobulin in some countries, and the occasionally limited rabies vaccine and rabies immunoglobulin availability because of production problems.
One way to assess the epidemiology of travel-associated illness in travelers and immigrants involves use of GeoSentinel, a global sentinel surveillance network established in 1995 through a collaborative effort from the International Society for Travel Medicine and the US Centers for Disease Control and Prevention (CDC) (5). We used the GeoSentinel database to assess geographic and demographic factors for a large number of patients who sought care at GeoSentinel sites for animal-related exposure (e.g., bite, scratch, lick on broken skin or mucous membrane) and required rabies PEP.

Dr. Gautret is a physician, parasitologist, and director of the Rabies Treatment Centre and of the Travel Clinic at Marseille University Hospital. He coordinates the Epidemic Intelligence and Response program for EuroTravNet. His professional interests include zoonoses, tropical and travel medicine, Hajj medicine, and medical parasitology.

Acknowledgments

Additional members of the GeoSentinel Surveillance Network who contributed data are (listed in descending order of amount contributed): Holly Murphy, CIWEC Clinic Travel Medicine Center, Kathmandu, Nepal; Annelies Wilder-Smith, Tan Tock Seng Hospital, Singapore; Jean Delmont, Hôpital Nord, Marseille, France; Joseph Torresi and Graham Brown, Royal Melbourne Hospital, Melbourne, Australia; Yukihiro Yoshimura, Natsuo Tachikawa, Hanako Kurai, and Hiroko Sagara, Yokohama Municipal Citizen's Hospital, Yokohama, Japan; Frank von Sonnenburg; University of Munich, Munich, Germany; Shuzo Kanagawa, Yasuyuki Kato, and Yasutaka Mizunno, International Medical Center of Japan, Tokyo, Japan; Annemarie Hern, Worldwise Travellers Health and Vaccination Centre, Auckland, New Zealand; François Chappuis and Louis Loutan, University of Geneva, Geneva, Switzerland; Jay S. Keystone and Kevin Kain, University of Toronto, Toronto, Ontario, Canada; Martin Grobusch, Peter de Vries, and Kartini Gadroen, University of Amsterdam, Amsterdam, the Netherlands; Johan Using, Gabrielle Fröberg, Helena Hervius Askling and Ulf Bronner, Karolinska University Hospital, Stockholm, Sweden; Michael D. Libman, Brian Ward, and J. Dick Maclean, McGill University, Montreal, Quebec, Canada; Christophe Rapp and Olivier Aoun, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France; Luis M. Valdez and Hugo Siu, Clínica Anglo Americana, Lima, Peru; JaKob Cramer and Gerd-Dieter Burchard, Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany; Phi Truong Hoang Phu, Nicole Anderson, Trish Batchelor, and Dominique Meisch, International SOS Clinic, Ho Chi Minh City, Vietnam; Mogens Jensenius, Oslo University Hospital, Oslo, Norway; David G. Lalloo and Nicholas J. Beeching, Liverpool School of Tropical Medicine, Liverpool, UK; William Stauffer and Patricia Walker, University of Minnesota, St. Paul, Minnesota, USA; Kass, Robert, Travellers Medical and Vaccination Centres of Australia, Adelaide, Australia (Dec 1997–Mar 2001 only); N. Jean Haulman, David Roesel, and Elaine C. Jong, University of Washington and Harborview Medical Center, Seattle, Washington, USA; Andy Wang and Jane Eason, Beijing United Family Hospital and Clinics, Beijing, Peoples Republic of China; Brian Kendall, DeVon C. Hale, Rahul Anand, and Stephanie S. Gelman, University of Utah, Salt Lake City, Utah, USA; Lin H. Chen and Mary E. Wilson, Mount Auburn Hospital, Harvard University, Cambridge, Massachusetts, USA; Udomsak Silachamroon, Mahidol University, Bangkok, Thailand; Sarah Borwein, TravelSafe Medical Centre, Hong Kong Special Administrative Region, China; Perry J. van Genderen, Havenziekenhuis en Instituut voor Tropische Ziekten, Rotterdam, the Netherlands; Jean Vincelette, Centre Hospitalier de l’Université de Montréal, Montreal,; Alejandra Gurtman, Mount Sinai Medical Center, New York City, New York, USA (Oct 2002–Aug 2005 only); Phyllis E. Kozarsky, Henry Wu, Jessica Fairley, and Carlos Franco-Paredes, Emory University, Atlanta, Georgia, USA; Patricia Schlagenhauf, Rainer Weber, and Robert Steffen, University of Zürich, Zurich, Switzerland; Johnnie Yates, Vernon Ansdell, Kaiser Permanente, Honolulu, Hawaii, USA (Oct 1997–Jan 2003 only); Marc Mendelson and Peter Vincent, University of Cape Town and Tokai Medicross Travel Clinic, Cape Town, South Africa; Frank Mockenhaupt and Gunder Harms, Berlin, Germany; Cecilia Perret and Francisca Valdivieso, Pontificia Universidad Católica de Chile, Santiago, Chile; Patrick Doyle and Wayne Ghesquiere, Vancouver General Hospital and Vancouver Island Health Authority, Vancouver and Victoria, British Columbia, Canada; John D. Cahill and George McKinley, St. Luke’s-Roosevelt Hospital Center, New York; Anne McCarthy, University of Ottawa, Ottawa, Ontario, Canada; Eric Caumes and Alice Pérignon, Hôpital Pitié-Salpêtrière, Paris, France; Susan Anderson, Palo Alto Medical Foundation, Palo Alto, California, USA; Noreen A. Hynes, R. Bradley Sack, and Robin McKenzie, Johns Hopkins University, Baltimore, Maryland, USA; Vanessa Field, InterHealth, London, UK; Bradley A. Connor, Cornell University, New York, New York, USA; Robert Muller, Travel Clinic Services, Johannesburg, South Africa (May 2004–Jun 2005 only); David O. Freedman, University of Alabama at Birmingham, Birmingham, Alabama, USA; Stefan Hagmann and Andy O. Miller, Bronx-Lebanon Hospital Center, Bronx, New York, USA; Effrossyni Gkrania-Klotsas, Addenbrooke's Hospital, Cambridge, UK; Shiri Tenenboim, Klinik Kominote IsraAid Community Health Clinic, Léogâne, Haiti (only); Nancy Piper Jenks and Christine Kerr, Hudson River Health Care, Peekskill, New York, USA; Carmelo Licitra and Antonio Crespo, Orlando Regional Health Center, Orlando, Florida, USA; Francesco Castelli and Giampiero Carosi, University of Brescia, Brescia, Italy; Paul Holtom, Jeff Goad, and Anne Anglim, University of Southern California, Los Angeles, California, USA (Apr 2007–Dec 2009 only).
This work was supported by CDC (cooperative agreement U50 CK000189).

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Figures

Tables

Technical Appendix

Suggested citation for this article: Gautret P, Harvey K, Pandey P, Lim PL, Leder K, Piyaphanee W, et al. Animal-associated exposure to rabies virus among travelers, 1997–2012. Emerg Infect Dis. 2015 Apr [date cited]. http://dx.doi.org/10.3201/eid2104.141479
DOI: 10.3201/eid2104.141479
1Additional members of the GeoSentinel Surveillance Network who contributed data are listed at the end of this article.
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